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SUMMARY

Salt-free dextran given intravenously to a patientwith nephrotic oedema had no effect on his clinicalcondition.Dextran produced an immediate increase of about

30% in the blood-volume, with no symptoms or signsof circulatory overloading.

’

No diuresis resulted from this haemodilution.No dextran was detected in the oedema fluid during and

after the injections or in tissues examined post mortemtwo months after the last infusion.

We wish to thank Dr. Frank Fletcher, of Messrs. BengersLtd., for his ready assistance and for examining the tissuesfor dextran ; Dr. A. H. T. Robb-Smith for permission toquote from pathological reports ; and Mr. J. R. P. O’Brienfor much valuable discussion.

REFERENCES

Archer, H. E., Robb, G. D. (1925) Quart. J. Med. 18, 274.Bull, J. P., Ricketts, C., Squire, J. R., Maycock, W. d’A., Spooner,

S. J. L., Mollison, P. L., Paterson, J. C. S. (1949) Lancet, i, 134.Engstrand, L., Åberg, B. (1950) Ibid, i, 1071.Folin, O., Wu, H. (1920) J. biol. Chem. 41, 367.Goldenberg, M., Crane, R. D., Popper, H. (1947) Amer. J. clin. Path.

17, 939.Grönwall, A., Ingelman, B. (1945) Acta physiol. scand. 9, 1.Hehre, E. J. (1946) J. biol. Chem. 163, 221.Howe, P. E. (1921) Ibid, 49, 109.Klevås, S. (1944) Svensk. Kem. Tid. 56, 262.Renfrew, A. G., Cretcher, L. H. (1949) J. Amer. pharmaceut. Ass.

38, 177.Thorsén, G. (1949) Lancet, i, 132.

— (1950) see Ibid, ii, 637.Turner, F. P., Butler, B. C., Smith, M. E., Scudder, J. (1949) Surg.

Gynec. Obstet. 88, 661.Wallenius, G. (1950) Scand. J. clin. Lab. Invest. 2, 228.

FOUR CASES OF APPENDICITIS IN ONE

FAMILY IN A WEEK

J. M. E. JEWERSM.B. Aberd., F.R.C.S.E.

SENIOR SURGICAL REGISTRAR, WEYMOUTH AND DISTRICT

HOSPITAL, WEYMOUTH

THE occurrence of appendicitis in four children of a

family of six within the space of six days seems unusualenough to be put on record. Altogether five membersof the family were admitted to this hospital in a week,but in the fifth case the abdominal pain was probablydue to a mild gastro-enteritis.

CASE-RECORDS

Case I.-Girl, aged 6 years. Admitted on Nov. 24, 1951.Had complained of intermittent periumbilical pain for lastthree days, constant in right iliac fossa for 14 hours. Vomited6-8 times during previous 48 hours. Bowels open on previousevening ; stools green. Had been treated for ringworm ofscalp with X rays and pronounced cured 10 days beforeadmission.

0)t examination: Desperately ill, with white face, blackhollows below eyes, and tongue furred and dry. Fauces

injected. Bare area of scalp 2 x 2 in. over left parietalbone (hair cut short for treatment of ringworm). Generalisedtenderness of abdomen, most definite over McBurney’s point.Per rectum : tender over pouch of Douglas, and mass palpableby tip of examining finger. Temperature 103°F, pulse-rate150, and respirations 34 per minute.

Operation (Nov. 6) : Right paramedian incision. A little

pale yellow opaque fluid escaped on opening peritoneum,well-marked general peritonitis present. Appendix gangrenous,perforated, and covered with omentum which oozed puswhen touched. Coil of terminal ileum was adherent toinflamed omentum and appendix. Omentum, ileum, andfibrin had formed walls of abscess, which had burst its con-fines. Appendix was removed and drain inserted deep torectus muscle. Pulse-rate at start of operation 154, andwhen patient left theatre " about 200."

Postoperative Ti-eatntent.-21,1, pints of 1! 5th physiologicalsaline and 5% dextrose given intravenously ; 100,000 units ofpenicillin four-hourly and 0’5 g. of streptomycin intramuscularlythrice daily ; 200 mg. of Aureomycin ’ given intravenouslysix hours after operation. Toxaemia profound for 18 hours,

when general condition slowly improved. Bowels openedspontaneously 52 hours after operation.Case 2.-Boy, aged 7 years. Admitted on Nov. 28. Had

been " unwell " for a few days. Pain around umbilicus forthree hours, worst in right iliac fossa. Bowels opened threetimes on day of admission. Nausea but no vomiting.On examination: Healthy looking boy who gave a good

story and answered questions definitely. Tongue clean andbreath pleasant. Throat and lungs normal. Abdomen

slightly tender over McBurney’s point on deep palpation,with slight muscle-guarding. Per rectum: tendernesshigh up on right side of rectum. Temperature 100’2°F,pulse-rate 80, and respirations 22 per minute.

Diagnosis Early catarrhal appendicitis.Operation (Nov. 28) : Begun 41/2 hours after first complaint

of abdominal pain. Right paramedian incision. Appendix4 in. long lying over brim of the pelvis ; proximal 21)’2 in.healthy, but the distal li/2 in. grey-green and distendedto diameter of 1/2 in. On applying tissue forceps on healthyportion of the appendix, diseased portion burst, adjacent swabbeing showered with beads of brownish-yellow and foul-smellingfluid. Appendix was removed and wound closed withoutdrainage. Postoperative course uneventful.Case 3.-Girl, aged 6 years (twin sister of case 1). Admitted

on Nov. 29. Had been getting general abdominal pain for24 hours, with nausea. Bowels open 5 A.M. on day ofadmission. Treated for threadworms at intervals over

previous two years.On examination: : Healthy looking girl. One enlarged

and slightly tender cervical gland, 1 X 3/4 in., on right sideof neck. Fauces and lungs normal. Abdomen soft withdiscomfort only in right iliac fossa. Per rectum : tenderon right side. Temperature 99°F, pulse-rate 104, and

respirations 20 per minute.Diagnosis: : In view of findings in case 2 acute appendicitis

or mesenteric adenitis was diagnosed.Operation (Nov. 29) : Right paramedian incision. Appendix

looked congested, with distended blood-vessels in outercoat. Dozens of enlarged juicy mesenteric glands extendingfrom meso-appendix up to region of pancreas. Appendixremoved and wound closed. On opening appendix, foundto be congested, with swollen mucosa and mucopus at distalend of lumen containing one threadworm.Case 4.-Boy, aged 121 years. Admitted on Nov. 30.

Had been having pain in right iliac fossa for 24 hours, resem-bling but worse than pain felt in same place at intervals forsix months. Tonsils removed a year ago, since when has hadconstant " sniff " due to excessive secretion from left nostril.On examination: : Healthy looking boy. Clear discharge

from left nostril. Throat and lungs normal. Tongue furredand breath offensive. Tender in right iliac fossa on deeppalpation. Per rectum : slight tenderness on right side.

Temperature 99°F, pulse-rate 70, and respirations 20 per minute.Diagnosis : Early catarrhal appendicitis or mesenteric

adenitis.

Operation (Nov. 30) : Right paramedian incision. Appendixlooked congested. A lymph-gland in meso-appendix measured1 X 3/4 in. and was red and juicy. Numerous similar

glands seen in ileocaecal region of mesentery. Appendixremoved and wound closed. Mucosa of appendix found to bediffusely swollen, with an area of haemorrhage and ulcerationat mid-point.Case 5.-Girl, aged 10’i, years. Admitted on Dec. 1, general

abdominal pain for 24 hours, making her double up. Nonausea or vomiting. Bowels opened three times on day -ofadmission, said to look normal. No recent sore throat orcoryza.On examination: : Healthy looking girl. Tongue furred

and throat red. Slight tenderness on deep pressure in rightiliac fossa. Per rectum : slight general discomfort. Tempera-ture 98’8°F, pulse-rate 90, and respirations 20 per minute,cell-count 8000 per c.mm.

Diagnosi,s : ? Alimentary upset.

COMMENTS

These four cases provided considerable food for

thought. Cases 1 and 2 obviously had highly infectedappendices ; the wall of the appendix rapidly swelledsufficiently to occlude the lumen, resulting in theobstructive type of appendicitis. No fsecolith or oldfibrous stricture, which might have caused mechanical

1164

obstruction, was seen. Case 3 was known to haveharboured threadworms for two years and presumablythese were responsible for the changes seen in her

appendix. Case 4 had a definite catarrhal appendicitis.Whether the changes found in his appendix began asthe follicular appendicitis mentioned by Aird (1949),which he says may accompany a non-specific mesentericadenitis, is an interesting question. Certainly the glandsseen in the mesentery in case 4 resembled those in non-specific adenitis, but in that condition there is usually ahigher temperature and more severe pain.

REFERENCE

Aird, I. (1949) Companion in Surgical Studies. Edinburgh; p. 707.

Medical Societies

HEBERDEN SOCIETY

THIS society met in London on Dec. 7 and 8, underthe presidency of Sir HENRY COHEN.

ANAEMIA OF RHEUMATOID ARTHRITIS

Dr. M. R. JEFFREY (Bath) said that the anaemia, ofrheumatoid arthritis was essentially a normocyticanaemia with decrease in the number of red cells andin their haemoglobin content ; red-cell fragility, haemo-lysis, and hsemodilution probably played no part in it. Theansemia varied with the activity of the rheumatoid

process but not with the patient’s age or sex or withthe duration of the disease. Over three hundred testshad shown a low plasma-iron level which could not becorrected by short courses of cortisone but could becorrected-sometimes for months-by intravenous iron.He and his associates had used a kind of " iron tolerancetest " in which gr. 9 of ferrous iron and a large dose ofascorbic acid were given by mouth to the fasting patient,whose plasma-iron content was subsequently measured.Some patients, mostly women, quickly responded witha large rise of plasma-iron ; but others who had, he con-sidered, a specific abnormality of iron metabolism did not.It was unlikely that decreased iron availability in thegut explained this failure ; there was no change in theplasma level of the specialised globulin responsible foriron transport, nor was there evidence of significantlyincreased removal of iron from the plasma. He con-cluded that in this disease there must be impairedabsorption of iron from the gut. Even when the levelof plasma-iron was corrected, however, the anaemia didnot always improve.

Dr. J. J. R. DUTHIE (Edinburgh) remarked that thepossibility of refractory protein-iron binding might beinvestigated ; and Dr. J. H. H. GLYN stated that inhis experience intravenous iron therapy sometimes pro-duced a rapid rise of haemoglobin before there wasevidence of bone-marrow response.

PRIMARY OSTEO-ARTHRITIS

Dr. ROBERT MooRE (Manchester) made a plea forthe recognition of a certain kind of osteo-arthritis as adistinct disease. Although degenerative joint diseasewas regarded as a wearing-out process, since it particu-larly attacked joints which had suffered undue strainfrom weight-bearing, deformity, or previous disease,there were cases whose evolution was different and which

presented a different pattern ; and these he classifiedas primary degenerative osteo-arthritis. Of 391 cases ofosteo-arthritis in Manchester in the last three years hehad made a special study of 196. Of these, 120 were ofprimary osteo-arthritis, nearly 80% of them being inwomen at or near the menopause. The characteristicfeatures of the disease included a tendency for certainjoints, particularly the distal interphalangeal and first

carpometacarpal joints, to be affected, although no

joint was immune. Each joint went through two stages- acute and chronic. In the acute phase there was

spontaneous joint pain, often in waves and especiallytroublesome at night ; this was described as a burning,bursting, or tingling pain. The affected fingers wereswollen and reddened, and though this disorder wasoften diagnosed as rheumatoid arthritis the peripheralvascular abnormalities and characteristic spindling ofthis disease were absent. The erythrocyte-sedimentationrate was often increased, but not to the great extentfound in rheumatoid arthritis. Small cystic swellingssometimes developed over the terminal interphalangealjoints ; these might even be opened by the patient inan attempt to relieve her pain, with the subsequentdischarge of a glairy colourless fluid. In other parts ofthe body pain was of a deep, aching nature and wasmade worse by cold, movement, or venous occlusion.After several months the acute phase subsided, leavinga deformed but painless hand with bony outgrowthsincluding Heberden’s nodes. Permanent crippling wasvery rare. Other features which differentiated thisarthritis from the rheumatoid variety were the absenceof constitutional symptoms and of soft-tissue lesions(as in bursae or tendon sheaths), nodules, rashes, andeye involvement. It did not respond to cortisone, andthe differential agglutination titre (Rose’s test) and otherserological tests usually positive in rheumatoid arthritiswere consistently negative.The meeting agreed that this concept of a specific

degenerative joint disease was less sterile for researchin osteo-arthritis than the old idea of " wearing out."

BIOCHEMICAL ABNORMALITIES OF RHEUMATOID

ARTHRITIS

Prof. N. F. MACLAGAN listed certain biochemicalabnormalities of rheumatoid arthritis. The serum-

albumin was reduced, but the globulin, :-globulin, andfibrinogen were increased. These changes were reflectedby the various flocculation tests, including colloidal goldand thymol turbidity. Liver function tests and endo-

genous steroid metabolism showed no constant changesor were normal. If rheumatoid arthritis and ankylosingspondylitis were compared by the frequency of abnor-mality of serum albumin and globulin and of theflocculation tests, it was found that significant differencesexisted between the two diseases which were not accountedfor by differences in age and sex of the patients.

Dr. E. G. L. BYWATERS noted that not enough caseshad yet been investigated as regards serum-fibrino-

gen and erythrocyte-sedimentation rate. He wonderedif differences in the activity of the disease process mightaccount for these other differences.

CLINICAL ASSAY OF A.C.T.H.

Dr. BARBARA ANSELL (Taplow) emphasised thatdifferent batches of A.C.T.H. differed widely in theirantirheumatic effects. No form of biological assay hadyet been systematically tested against the clinical effectsin rheumatoid arthritis. Furthermore, results of differentanimal assays were not mutually congruous. Therewas great need for a yardstick of antirheumatic actionagainst which other tests might be evaluated. Unfor-tunately, the difficulties of clinical assay were many.They had tried various systems.In one, consecutive seven-day courses of intramuscular

A.C.T.H. were given to a patient with disseminated lupuserythematosus. The effect on the rash, fever, and pulmonarycomplications was noted. By this means it was clearly shownthat some batches of A.c.T.H. were far less effective than abatch of known potency. It was not possible, however, tosay how much less effective, since after seven weeks it was

apparent that the patient’s response to even the potentbatch had decreased. Subsequently they had tried alter-

nating periods of treatment, with intervals of no treatment,in patients with rheumatoid arthritis. A fixed dose of hor-mone was given and the various preparations comparedaccording to the response, which was measured by clinicaltests such as pain on pressure, strength of grip, speed of